What Qualities do Women Want in an OBGYN?

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I recently read an insightful article that gave a good summary of the qualities women are obgyn picseeking in an OBGYN. Recent reports show that many young women prefer female physicians compared to their male colleagues. Assuming that physicians are knowledgeable and skilled, is it communication skills that give female OBGYNs the edge?

To better understand the softer side of feminine communication, here’s a list of techniques for improving your communication skills during the patient-doctor visit. Being caring and compassionate is a good place to start. Beyond that, in your patient encounter:

  • Introduce yourself with a warm greeting or handshake, showing politeness, respect and approachability.
  • If possible, be sitting down to show that you have time to listen to all the reasons for the visit.
  • Repeat back to the patient your understanding of her concerns to show that she has been heard.
  • Try to warn in advance about any parts of the exam that might be uncomfortable. If you cause pain such as by drawing blood, or palpating a tender spot, say you are sorry for causing the discomfort but that it has to be done as part of the exam.
  • Give good instructions about medication use and show you are interested in her understanding what she needs to do.
  • Offer resources for more information to facilitate doing individual research about the topics that were discussed.
  • Give a good send off at the end of the visit by saying “Thanks for coming in” or “See you again next year” to show you appreciate her coming in for a visit. Sometimes the most important concern will be expressed as the patient gets up, walks to the door and stops, just before leaving.
  • Be a hero with the patient by following up on tests, returning calls or emails and being available to address concerns.

Being approachable, making time for the patient, helping her to be at ease during an exam,  listening to and caring about her concerns, and giving a good explanation about plans for treatment makes the OBGYN a physician whom patients look forward to see.

 

Gestational Diabetes now has a new test.

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Diagnosing GDMGestational Diabetes mellitus (GDM) is carbohydrate intolerance that begins or is first recognized during pregnancy. It is associated with increased maternal, fetal and neonatal risks. The prevalence of it is increasing in the U.S. probably due to the increasing rates of overweight and obesity. Testing for GDM may be about to be going through some changes.

The American College and Obstetricians and Gynecologists recommends a two step test, with a screening test being given between 24-28 weeks of pregnancy. If the test is not passed then a 3 hour glucose tolerance test is done to diagnose GDM. If the first and second tests are both positive, then the person has gestational diabetes mellitus, and the pregnancy is managed differently to minimize the additional risk.

In 2013 the American Diabetes Association decided that new guidelines for diabetes are to be promoted. The new standards of care are intended to provide clinicians and patients with the components of diabetes care, treatment goals, and tools to evaluate quality of care. Targets that are desirable for patients are provided.

Diabetes will now be classified as Type 1 where there may be absolute insulin deficiency, Type 2, a progressive lack of insulin secretion on the background of insulin resistance, and Gestational diabetes mellitus, diabetes diagnosed during pregnancy that is not clearly overt.

The diagnosis of diabetes used to be based on glucose measurement, either fasting or the 2 hour value during a glucose tolerance test. Recently an expert international panel has recommended that diabetes can also be diagnosed by a different test called hemoglobin A1C. The A1C test has advantages, including greater convenience, since fasting is not required, and greater analytical testing stability. The older established criteria of fasting blood glucose and 2 hour oral glucose test still remain valid.

These new criteria are: a A1C test over 6.5, or a fasting glucose over 126, or a 2 hour plasma glucose over 200 during an oral glucose tolerance test using 75 gm of glucose.

To accommodate this change, we will be starting to check the hemoglobin A1C level during the initial obstetric evaluation. I expect this will yield better diagnosis of gestational diabetes, with the benefit of better control. This should result in a decreased risk of having babies that are too large, lower chance of having a cesarean, less risk of having diabetes in the future and fewer problems with babies having breathing problems, low glucose levels, and jaundice.

Reference: doi: 10.2337/dc13-S011

Diabetes Care January 2013 vol. 36 no. Supplement 1 S11-S66

Should Doctors and Patients be Facebook Friends?

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SM iconsOne of the groups I’m involved with is the Physicians’ Electronic Health Record Coalition, or the PEHRC (pehrc.wordpress.com). Recently we were honored to have as our guest Dr. Humayan Chaudhry who is the CEO and President of the Federation of State and Medical Boards (FSMB). His organization is responsible for coordinating physician activity in the United States to help maximize patient safety. One of the subjects he discussed at our meeting is the huge increase in the use of social media by patients and by physicians, and how this practice is changing the way we practice medicine.

According to a recent survey, 87% of physicians use a social media website for personal use and 67% for professional use.  Also 35% of physicians have received Facebook friend requests from a patient and 16% have visited an online profile of a patient. Of the physicians who have received friend requests from a patient, 58% said they always rejected them. Some physicians feel that “friending” a patient through a personal Facebook page crosses the line between a professional and a personal relationship.

Dr Chaudhry’s group, the FSMB, has published guidelines for the appropriate use of social media in medical practice. Physicians are discouraged from interacting with patients on personal social networking sites like Facebook and physicians should never discuss treatment with patients on a personal social networking site. Information that could identify patients should never be provided. Patient privacy and confidentiality must be protected at all times. Physicians are encouraged to use separate personal and professional social media networking sites.

I think these guidelines make good sense. Social media have confused the distinctions between personal and professional identities. Some healthy separation is in order. So, if you are a patient, please don’t send me a request to be your Facebook friend. I’m honored to be your doctor, but I can’t cross the line between professional and personal by being your Facebook friend as well.

 

All about HPV

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HPv imageThere’s a lot of misunderstanding about HPV. If you get a phone call that your pap test is not normal, people tend to jump to the worst possible conclusion and believe that they now have cancer. In the great majority of cases there is no cancer at all, and what we are dealing with is a condition that might lead to cancer in the distant future if it is not properly treated.

HPV is a virus spread through vaginal, oral or anal sex through direct skin to skin contact. Sexual intercourse is not required to get it. It’s very common, and research suggests between 50 to 75% of all people who have sex will get it at some time during their lives. In most cases HPV exhibits no symptoms and in 90% of cases the immune system clears it within 2 years.

There are more than 100 types of HPV. About 12 types of HPV can cause genital warts. These types are called “low-risk” because they have very low cancer potential. About 15 types of HPV can cause cancer of the anus, cervix, vulva, vagina and penis, as well as cancer of the head and neck. These types are called “high-risk.” Just 2 types – 16 and 18, cause most cases of cervical cancer.

HPV harms the cervix by infecting cells, which may become abnormal and begin to grow differently. These changes may lead to cancer. They are known as dysplasia and are classified as mild, moderate, or severe. Both low risk and high risk HPV can cause abnormal cells to grow, but only the high-risk types increase the risk of cancer.

HPV infections that are not cleared by you body’s immune system are called persistent. Young women get rid of the virus quicker than older women. Also, women who smoke are more likely to have the virus persist. The longer the virus persists, and the older the woman, the greater the chance of developing pre-cancer of the cervix. When HPV is present, smoking doubles the risk of progression to severe dysplasia.

Men and women can pass HPV to each other. Since HPV usually does not cause any symptoms, if you have more than one partner over time it’s not possible to know who passed it to you, even if you are currently monogamous. In many cases an abnormal pap test result is from an exposure that happened years ago.

The pap test is the main screening test for early signs of abnormal growth in the cervix. Regular use of pap tests has greatly reduced the number of cases of cervical cancer in the U.S. An HPV test is also available and can identify 15 different high risk types. Currently, there are NO approved tests to detect HPV in men! While cervical cancer is the most common type of cancer associated with HPV, the virus can also lead to oral and anal cancers in men and women. It’s possible that in the future with the successful detection and treatment of cervical pre-cancer, the oral and anal cancers may become more common than cervical ones.

Abnormal pap results are usually evaluated by an office procedure called colposcopy. This looks at the cervix with magnification and a biopsy is taken to provide a more definite diagnosis. In many cases no treatment is needed. If a biopsy shows an abnormal finding, the type of treatment is determined by the woman’s age, the type of abnormal result (mild, moderate or severe) and how long the abnormal cells have been present. The LEEP procedure is one of the more common treatments used to remove pre-cancer. It’s effective and has a high rate of cure.

Prevention of HPV is best as there is currently no medication or treatment that completely destroys the virus. Limiting your number of sexual partners and using condoms will help protect you against HPV, herpes and other STDs. Condoms won’t protect you against virus transmitted through oral sex.

Vaccines are available to help protect against the worst types of HPV. The vaccines increase your immune response to fight the viruses. The vaccines are given in 3 doses over six months. The vaccines work best if they are given before the person has had sex. They can still be given if you are already infected with one type of HPV and will protect you against the other HPV types the vaccine prevents. The vaccines are not recommended for pregnant women but can be given during breastfeeding.

Getting vaccinated, limiting your exposure, and getting screening for cervical cancer and any follow-up tests that are recommended are the best ways to prevent the worst complication of HPV, cervical cancer.

Breast-Feeding Myths

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womanly art In the early 1970s less than 25% of new mothers tried to breast-feed their newborns. Now 75% of infants are receiving some breast milk. There is still much controversy about breast-feeding, as mothers that don’t breast-feed are often criticized, and there are debates about the right to breast-feed in public and the best age for weaning.

  1. Breast-feeding is natural. This depends on how you define the word “natural.” Breast milk is produced by the human body and for most of human history breast-feeding infants has been a basic fact of life. But its value as being wholesome and nutritious depends on what the mother has been eating, drinking and breathing. There are concerns about environmental contaminants that nursing mothers can’t control, and women have been arrested for feeding their infants milk contaminated by drugs, alcohol and even prescription medications.
  2. Formula is just as healthy as breast milk. Breast milk with its unique blend of proteins, fats, vitamins and carbohydrates conveys a range of additional benefits that go beyond simple nutrition, including decreasing the risks of ear infections, asthma, gastrointestinal ailments, diabetes, allergies, obesity and sudden infant death syndrome.
  3. One year is the best time for weaning. Most women aim to breast-feed for one year, but there’s nothing special about that amount of time. Most of the benefits of breast-feeding have already occurred by the end of the fourth month. The one year goal reflects our ambivalence about the breast in modern culture: it is both a symbol of maternal care and the epitome of a woman’s sexuality. As babies grown teeth, begin to walk and talk, the sexual begins to overshadow the maternal. Some women, however, discover how difficult it is to wean their children off breast milk and may continue it for years.
  4. Most American women breast-feed. Statistically that is true, as 75% try to breast-feed and 35% are still doing it at 3 months. This doesn’t show the large differences between races and classes. White, educated, older and married women are more likely to breast-feed. Lower income and minority mothers have fewer resources and face economic barriers as they are less likely to get paid maternity leave. Pumping – the solution for working mothers – is often not available at work due to a lack of a clean, safe and private space.
  5. Breast-feeding rates dropped in the 20th century because women entered the work force. U.S. breast-feeding rates actually began rising just as women entered the work force in large numbers in the 1970s. The women’s movement, which encouraged women’s entry to the workplace in the 1970s, was also instrumental in the resurgence of breast-feeding.

 

Did Lady Sybil Have to Die?

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Lady SybilLast week one of the most popular shows on television, “Downtown Abbey,” had one of its main characters, sweet Lady Sybil, die suddenly and without warning as a result of preeclampsia. Those of us who work in Obstetrics are well aware of the dangers of preeclampsia. We have patients who call and complain of headaches, swelling, and “the baby hasn’t been moving today.” This definitely gets our attention. We know the potential harm it can cause, and the risks to the baby and mother. But most people don’t think about it much, even women who are pregnant. So it’s a great public service to call attention to this problem and raise consciousness about it.

Preeclampsia is a life-threatening disorder that occurs only during pregnancy and the immediate post-partum period. It is characterized by a rapid progression of high blood pressure, swelling and protein in the urine that can lead to liver damage, bleeding, seizures, stroke and death.

The condition affects as many as 8% of pregnant women in the US every year. It’s one of the main reasons we see pregnant women every week at the end of the pregnancy and check their urine every visit. The condition causes stillbirths and can be a great risk to the mother’s health. Unfortunately, the symptoms can easily be overlooked, as was the case in the “Downtown Abbey” episode where the swelling of Lady Sybil’s feet and changes in her mental status were not given proper attention. Sometimes the pregnant woman may be advised to “not make a big deal about it.” Recognizing this condition early and treating it properly can make all the difference in the world.

If a pregnant woman notices problems with high blood pressure, swelling, sudden weight gain, nausea or vomiting, headaches, changes in vision, changes in mental status, or a decrease in the baby’s movement it is always best to tell your obstetrician about it.

Fortunately, there’s so much more that can be done for women who have this condition today compared to what was available one hundred years ago. The medications to control high blood pressure are much improved, and, as was recommended in the episode, delivery is usually the best treatment. Other medications such as Magnesium sulfate are administered in a hospital setting, usually with excellent results.

Becoming aware of this problem is the first step in detecting it and starting early treatment. If you suspect you may be developing preeclampsia, make sure your health care provider is aware too!

 

Apps for Obstetrics!

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Apps can be very helpful. I’m always asking my patients which apps they like for pregnancy. These are some that have been recommended to me:

1. My Days – Period and Ovulation

My DaysThis free, accurate app has is very helpful for determining the best days of fertility and improving your chances of becoming pregnant more quickly! It tracks periods and uses this information to predict fertility in the upcoming month.

Or… it can be used as a birth control method by knowing which are the most important fertile days and avoiding intercourse at that time.

2. What to Expect Pregnancy

What to Expect app

This very popular app includes a due date calculator, week-by-week details on your baby’s development, weekly baby illustrations, updates on your changing body, and countdown to your due date. You get daily tidbits of advice and it also includes helpful information for dads.

3. Simple Contraction Timer by iBirth

Contraction timerThe value of a contraction timer is in its simplicity and ease of use. This app makes timing of contractions during labor easy. It has a simple interface, tracks the duration of each contraction, tracks the intervals between contractions, and has a history report for tracking labor progress over time.

4. Baby Names!!

Baby names!!For people who would like some help in choosing a name, this app will show you the name’s meaning, pronunciation, gender and origin. It also includes graphs of a name’s popularity over time. For example, the most popular girls names now are Sophia, Isabella, Emma, Olivia, Ava and Emily! It links to Wikipedia and gives you oodles of information.

5. (iThankyou)

iThankyouThis app uses your phone’s camera to help you keep track of gifts received and who sent them. This mix of new and old approaches to writing thank you notes is integrated with your address book and allows you to easily write and address a hand-written thank you note or send a thank you email.

ObGyn Apps for Fitness

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We all know how important fitness is. Whether you’re male or female, young or old, it’s vital to your health. In this post we’re going to look at some favorite apps for fitness. I hope you enjoy them.

1. Nike Training Club.

Nike Training Club

This free app has hundreds of different workouts for women, all in a well-designed format. It’s easy to pick one, do it, and then keep track of  where you are in your fitness program.

2. Couch To 5K.

Couch to 5K

This app won the 2012 Appy Award in the Healthcare and Fitness category. It pledges to help even the most unprepared person to get in shape to run in a 5K race in just nine weeks. It’s fun, with different cartoon trainers, “ridiculously easy to use,” and requires just 20-30 minutes 3 times a week to get you to the finish line.

3. Pocket Yoga

Pocket Yoga

This yoga guide is one of the best apps of 2012 according to CNN and Mac Life magazine. There is an extensive dictionary of yoga poses and terms with exceptional yoga instructions that lead to three different variations of yoga, three difficulty levels and three durations, all for $2.99.

4. RunKeeper

Runkeeper

For people who like to get outdoors to workout, this free app can track your exercise outside using your phone’s GPS system, whether it’s by run, bike or hike. It alerts you to your stats and progress as you workout. You can save routes, compare your current with previous performances and sync your health data with other fitness apps. It’s a well-integrated and well-designed system.

5. Cardiio

Cardiio

This app uses innovative technology from MIT‘s Media Center to interpret your heart rate simply from the way that light is absorbed or reflected from your face each time your heart beats. It uses sophisticated software to track these tiny changes not visible to the human eye and calculates your heart rate which correlates with your fitness and potential life expectancy.

Understanding Hormone Therapy

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hormone imageAs women transition into menopause there is a gradual but steady decrease in ovarian hormones. This can cause a wide range of symptoms that can negatively affect daily activities and hurt the quality of life. Many women who are near menopause would have few dangers from receiving hormone replacement therapy (HRT), and for many the benefits outweigh the risks of taking them. Yet there are questions about the safety of taking hormones. Who should take them and who not?

There have been significant developments since the Women’s Health Initiative (WHI) report came out in 2002 and changed our beliefs in the value of hormone replacement therapy. The WHI was focused on heart disease, and some 70% of the women in the study were older than age 60. Women who were having menopausal symptoms were not allowed to be in the study, which may have biased the results. The results were mainly negative, and showed that HRT did not give a benefit in reducing heart disease. This caused skepticism about whether hormone therapy could ever be used safely. Now, years later, we can say that there was a mistake in interpretation by trying to extrapolate and apply the results to all women. Further information that has come out since the WHI report was published has shown that women in their 50’s who start HRT near the time of menopause have fewer cardiovascular problems and fewer deaths in general, compared with those who start HRT years later. This can be thought of as a window during which time therapy, if started, is safer. Even better, it has recently been confirmed that women who took only estrogen had a lower risk of getting heart disease, a lower chance of getting breast cancer, and a lower risk of colon cancer.

Here’s what recent research says about which women should be taking hormone replacement therapy:

Hot Flashes and related symptoms. About 70% of women who are going through menopause suffer from hot flashes, night sweats, dryness, difficulty in sleeping and other problems. In 20% of women the problems are serious enough to disrupt productivity and harm the quality of life. Estrogen is the best treatment for these symptoms. Studies have shown it can increase the production of neurotransmitters that improve mood, memory, attention, sleep and response to pain. If women can’t or don’t want to take hormones there are alternatives. There can also be relief from lifestyle changes such as avoiding too much caffeine or alcohol; increasing the amount of time spent exercising is very helpful.  Other medications to prevent bone loss are available, and for vaginal dryness a lubricant can be beneficial. But for women who are taking multiple medicines, it doesn’t make sense to take an antidepressant, a sleep aid and an anti-anxiety pill to do what estrogen alone can do better at less cost and with fewer side effects.

Breast Cancer. This is the biggest fear and the greatest reason that women avoid hormone therapy. The numbers tell a different story. The increase in risk is actually very small. In the group of women who take an estrogen with a progestin, the risk of breast cancer death is 2.6 per 10,000 women per year, compared with 1.6 women per 10,000 per year in the group taking no medication. Women in the group taking only estrogen had a 63% lower risk than the group on no medication, leading to consideration that the main risk is not estrogen, but may be the progestin ingredient of HRT, medroxyprogesterone. In hormone replacement therapy, the need for a progestin is based on whether or not the uterus is present, as taking progesterone protects against uterine cancer. One conclusion here is that if a woman has had a hysterectomy and thereby does not need progesterone as part of treatment, taking estrogen significantly reduces her risk of breast cancer.

Heart Disease. Observational studies have long shown that women who used estrogen had a lower risk of heart disease, but most were younger than 55 when they started taking the medication. Studies show that estrogen staves off hardening of the arteries but cannot undo the damage once it has occurred. The timing for starting HRT is crucial here. Starting it closer to the menopause increases the cardiovascular benefit.

Stroke. The WHI study showed that both estrogen alone and estrogen with progestin raised the risk of stroke and blood clots. The risks appear to be the same regardless of when the medication is started. Most experts advise avoiding HRT if you are at increased risk of having a stroke or blood clots. If you take it, a lower dose is safer.

Osteoporosis. Considering that 50% of women over 65 eventually develop osteoporosis, some say that this benefit of HRT in preventing osteoporosis has been improperly ignored. Having a fractured hip, getting fractures, or losing height are detrimental and dangerous. There are other medications for preventing osteoporosis, but they all have side effects of their own.

Diabetes. Taking hormones appears to reduce the risk of Type 2 diabetes, by 21% in the estrogen progestin group and by 12% in the estrogen alone group. More research is needed to evaluate this potential new benefit of HRT.

Whether HRT can be safely used is an important question. However, there is no simple correct answer. Many factors determine the correct choice for each person. When considering this question, there are 3 factors that profoundly affect the risk benefit profile for each person: age at initiation of therapy, hormone dose, and route of administration.

Age at HRT Initiation. The beneficial action of estrogen is its ability to prevent harmful deterioration over years that can irreversibly result in bone loss, vaginal and bladder atrophy and reduced skin elasticity. The timing of initiation of HRT is critical. Studies show there is a therapeutic window for starting therapy. If therapy is started before age 60 there is definitely a greater benefit in preserving the normal functioning of many types of tissue including bone, skin, and the urogenital, cardiovascular and nervous systems.

HRT Dosage. A second important influence on the risk benefit profile of HRT is the amount that is given. Substantial evidence exists that a low dose HRT dosage is effective in preventing bone loss and in treating menopausal symptoms with less bleeding and other side effects compared with higher doses. This is especially seen in the risk of stroke, which increases as higher doses of estrogen are used.

Route of HRT Administration. The use of HRT through patches, known as transdermal hormone therapy, has been shown to have a lower risk of venous thromboembolism compared with oral administration. People who are at greater risk of stroke such as those who have cardiovascular disease, multiple cardiovascular risk factors, history of venous thromboembolism, or known increased risk of stroke through genetic causes need to be aware of the lowered risk through transdermal use. Recent studies show that the use of transdermal estrogen does not result in an increased risk of blood clots and stroke, even when used in high-risk patients.

Individualizing HRT Choices. A decision about whether to start HRT should be based on an assessment of the risks and benefits as it pertains to you. Starting HRT in early menopause or peri-menopause is associated with many benefits and low risk. Multiple studies support the protective effect of estrogen therapy on cardiovascular disease, dementia and overall mortality.

Women with an intact uterus are usually given estrogen with progesterone to help protect the uterus from overstimulation. An advantage of using a low dose estrogen is that it can be balanced with a low dose progestin to minimize bleeding and undesirable side effects. In many cases using a transdermal delivery system will minimize the effect of estrogen on the liver, which decreases the production of blood clotting proteins and lowers the risk of blood clots or a stroke. We need to consider contraindications such as a previous history of breast cancer, blood clots or undiagnosed vaginal bleeding. If you meet the proper criteria, your risk-benefit analysis can show that hormone therapy will give many advantages resulting in an improved quality of life. It’s something important to think about and discuss with your health care professional to make the right decision for you.

My Visit to the West Wing!

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It all started with an invitation I received to go to a Town Hall Meeting at the White House! I’ve been active in Health Information Technology and I was asked to attend this meeting as a local leader representing Maryland physicians. Naturally this was an invitation I could not refuse! The meeting was held at the Eisenhower Executive Office Building.

I had a great time hearing about the expanded use of electronic health records and how they present many exciting opportunities for improving our health care. Dr Farzad Mostashari, the National Coordinator for Health Information Technology, lead a spirited discussion about the potential this new technology has for the future.

Later on back in my office I happened to be bragging (just a little) about my trip to the White House and one of my patients said that she worked there and would I like to see the West Wing? She would arrange for a private tour and would be our guide. I couldn’t wait to have this once-in-a-lifetime visit!

My wife and I sent in our security information, and then had an appointment to visit the West Wing. We went through security and were at the ground floor entrance. We went inside to the lobby, then saw the Navy Mess and the entrance to the Situation Room. During this part of the tour no pictures are allowed. Soon we went upstairs and saw the Cabinet Room. Here’s an official picture of how it looks.

The interesting thing about it was that outside in the hallway there’s a large box containing 50 or so numbered small cubicles. We were told that everyone who enters the Cabinet Room has to surrender their cell phone and have it placed there- No Exceptions!

Soon we had the great thrill of seeing the Oval Office. Here’s a recent picture of it and this is just how it looked to me.

All along the periphery of the rug were famous quotations. I later found out they were selected by President Obama and are from Franklin D. Roosevelt: “The Only Thing we have to Fear is Fear Itself,” from Martin Luther King, Jr.: “The Arc of the Moral Universe is Long, But it Bends Towards Justice,” from Abraham Lincoln: “Government of the People, By the People, For the People,” from Theodore Roosevelt: “The Welfare of Each of Us is Dependent Fundamentally Upon the Welfare of All of Us,” and from John F. Kennedy: ” No Problem of Human Destiny is Beyond Human Beings.”

We were also given a nice booklet that described the West Wing in more detail and it had a welcome from the President.We then departed through the north entrance to visit the Press Briefing Room.

The room was surprisingly small. I suppose it gets quite crowded at times. There was a cameraman there who cheerfully informed us the Redskins were ahead.

 We had our pictures taken once again and then it was time to go. Wow, what a fantastic visit it was!

It was inspiring to see where the President works. There were many pictures of people he met, and I understand the pictures are changed frequently. The guards were all very courteous and helpful. It was a day I’ll never forget!